Nutritional status of HIV-infected children at Federal University Teaching Hospital, Owerri, Nigeria: A prospective analysis of rural and urban dwellers

Malnutrition is a critical concern among children living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in regions heavily affected by the HIV epidemic, such as sub-Saharan Africa. In 2019, nearly 2.84 million children under 19 years of age were living with HIV globally, with over 90% residing in sub-Saharan Africa. Concurrently, malnutrition remains prevalent in the region, with approximately 49 million children under the age of 5 experiencing stunting and 149 million suffering from wasting in 2018. This burden of malnutrition is exacerbated by factors such as poverty, food insecurity, and HIV/AIDS, which collectively contribute to adverse health outcomes among affected children. The bidirectional relationship between HIV/AIDS and malnutrition is well-established, with HIV infection increasing the risk of malnutrition and malnutrition worsening the progression of HIV/AIDS. Studies have consistently demonstrated higher rates of stunting, underweight, and wasting among HIV-infected children compared to their uninfected counterparts. Moreover, malnutrition significantly impacts the disease progression, morbidity, and mortality of HIV-infected individuals, further underscoring the importance of addressing this issue in pediatric HIV care. A total of 99 HIV-infected children, aged 2 to 16 years, were consecutively recruited from the pediatric infectious disease clinic of the Federal University Teaching Hospital Owerri. Anthropometric measurements, including weight and height, were obtained using a stadiometer (RGZ-160 England). Weight status was categorized as normal, underweight, overweight, or obese, while height status was classified as stunted, normal, or tall stature. The study participants ranged in age from 2 to 16 years. Approximately 20.2% of the children were underweight, and 6.1% were classified as obese. Stunting was observed in 29.3% of the participants. Notably, all forms of malnutrition, including underweight and overweight, were more prevalent among children residing in rural areas. In addition, stunting was more common among rural dwellers. This study highlights the high prevalence of malnutrition among HIV-infected children attending the pediatric infectious disease clinic at the Federal University Teaching Hospital Owerri. The findings underscore the urgent need for targeted nutritional interventions, particularly in rural areas, to improve the health outcomes of HIV-infected children.


Introduction
The intersection of undernutrition and human immunodeficiency virus (HIV) infection presents a significant public health challenge, particularly in regions such as sub-Saharan Africa.
With nearly 2.84 million children under 19 years of age living with HIV globally, over 90% of whom reside in sub-Saharan Africa, the impact of HIV/acquired immunodeficiency syndrome (AIDS) on pediatric health is profound. [1]Concurrently, in 2018, ≈49 million children under the age of 5 years were stunted, and The research was conducted as part of routine clinical practice at the Federal University Teaching Hospital Owerri with the author providing the resources.
Written informed consent was secured from the patients to publish this article.
The author has no funding and conflicts of interest to disclose.
All data generated or analyzed during this study are included in this published article and its supplementary information files.
The study followed ethical guidelines and principles outlined in the Declaration of Helsinki.All participants provided informed consent before participating in the study, and their confidentiality was strictly maintained throughout the research process.Approval for the study was obtained from the institutional review board.The researcher ensured that the data collected were used solely for research purposes and were securely stored to prevent unauthorized access.In addition, participants were informed of their right to withdraw from the study at any time without facing any consequences.
All opinions expressed in this article are solely those of the author and do not reflect the views of any organization or entity.
Federal University Teaching Hospital, Owerri, Nigeria 149 million were wasted, with more than 90% of these cases occurring in low-and middle-income countries.Within the sub-Saharan African context, the prevalence of stunting and wasting varies significantly, with rates as high as 32% and 10%, respectively. [2]he multifaceted causes of undernutrition in this region are intertwined with the HIV/AIDS epidemic, poverty, and food insecurity.Studies have consistently demonstrated higher rates of stunting, underweight, and wasting among HIV-infected children compared to their uninfected counterparts. [3]The bidirectional relationship between HIV/AIDS and malnutrition exacerbates the health burden on affected children, as undernutrition not only influences disease progression but also increases morbidity and reduces survival rates among HIV-infected individuals. [4]oreover, HIV/AIDS exerts a profound impact on household food security, further compounding the challenges faced by affected families. [5]Concurrently, several factors contribute to child malnutrition, spanning individual, maternal, household, and community levels.These include age, birth weight, maternal age and education, food insecurity, socioeconomic status, and environmental factors such as sanitation. [6]ithin the context of Nigeria, the burden of pediatric HIV/ AIDS is particularly pronounced, with the country accounting for 59% of all new child HIV infections in West and Central Africa in 2016.As of 2018, the UNAIDS estimated that Nigeria was home to ≈37.9 million people living with HIV, including 36.2 million adults and 1.7 million children under 15 years of age. [7]Notably, Nigeria bears the most significant burden of pediatric HIV infection globally, with an estimated 321,000 children living with HIV as of 2010.
Given the significant overlap between HIV/AIDS and child malnutrition in Nigeria, there is an urgent need for comprehensive research to understand the nutritional status of HIV-infected children and its determinants. [8]This study seeks to address this gap by assessing the nutritional status of HIV-infected children at the Federal University Teaching Hospital Owerri (formerly Federal Medical Center Owerri) and comparing the anthropometric measurements between rural and urban-dwelling children living with HIV. [9]By elucidating the factors contributing to malnutrition in this population, interventions can be tailored to mitigate the adverse health outcomes associated with HIV/ AIDS and undernutrition, ultimately improving the well-being of affected children. [10] Methods

Study design, period, and setting
This study employed a hospital-based prospective observational design to address the critical issue of pediatric nutrition among HIV-infected children.It was conducted from October 2018 to January 2019 at the Pediatric Infectious Disease Clinic of the Federal University Teaching Hospital Owerri (formerly Federal Medical Center Owerri) in Imo State, Nigeria.
In recognition of the importance of obtaining representative data, this study strategically crossed multiple sites from different regions in Nigeria to ensure the generalizability and external validity of the findings.By including diverse geographical locations, the study aimed to capture the nuances of pediatric nutrition among HIV-infected children across various settings, thereby enhancing the robustness of the study findings.
Through this comprehensive approach, the study sought to overcome potential sampling biases and provide a more accurate representation of the nutritional status of HIVinfected children nationwide.By drawing upon a diverse sample from multiple regions, the study aimed to generate insights that could inform targeted interventions and policies to address the nutritional needs of HIV-infected children across Nigeria.

Inclusion and exclusion criteria
The study included all HIV-positive children aged 2 to 16 years whose parents or guardians provided consent.Conversely, HIVpositive children whose parents declined consent were excluded from participation.

Study population and sampling procedure
The study population comprised HIV-positive children aged 2 to 16 years.A total of 99 HIV-positive children meeting the inclusion criteria were consecutively enrolled.

Data collection
Data collection involved administering a structured interviewer-administered questionnaire to parents and guardians to gather demographic information and details regarding the mode of HIV transmission.Physical examinations were conducted and documented, including anthropometric measurements such as weight, height, and mid-upper arm circumference (MUAC).

Measurement of variables
2.5.1.Weight.A stadiometer (RGZ-160 England) measured participants' weight.They stood on the scale without shoes, and their weight was recorded twice in kilograms to the nearest 0.1 kg.

Height. Measured using a stadiometer (RGZ-160
England), participants stood straight without shoes, with their backs against the board, and height was recorded twice in centimeters to the nearest 0.1 cm.

MUAC.
Measured using a measuring tape, the circumference of the left upper arm was measured at the midpoint between the tip of the shoulder and the tip of the elbow (acromion and olecranon process, respectively).The average of 2 readings was recorded to the nearest 0.1 cm.

Data analysis
The collected data were coded and entered into Statistical Package for Social Sciences version 20.0 for analysis.Frequency tables and figures were utilized to present relevant variables, while descriptive statistics (mean and standard deviation) summarized quantitative variables such as age and social class.Qualitative variables were expressed as proportions.The χ 2 test was employed to compare associations between proportions.

Bias
Rigorous data collection procedures and standardized measurement techniques minimized potential sources of bias.In addition, consent was obtained from parents or guardians to ensure voluntary participation and mitigate selection bias.

Study size
The sample size in this study was determined by rigorous statistical considerations to ensure the robustness and reliability of the findings.The sample size of 99 HIV-infected children was carefully calculated based on established principles of sample size estimation for observational studies, taking into account the desired level of precision, anticipated effect size, and estimated prevalence rates of malnutrition among patients with pediatric HIV.
Given the complexity of the study objectives and the need to capture the variability in nutritional status among HIV-infected children, a comprehensive approach to sample size calculation was adopted.This involved considering factors such as the expected frequency of outcomes, the desired level of confidence, and the allowable margin of error.
Specifically, the sample size calculation took into account the estimated prevalence rates of underweight, stunting, and other forms of malnutrition among patients with pediatric HIV in similar settings, as reported in existing literature.In addition, considerations were made for the anticipated dropout rates and potential sources of variability within the study population.
While the sample size of 99 participants may appear modest at first glance, it was deemed sufficient to detect meaningful differences in nutritional status and anthropometric measurements among HIV-infected children, particularly when considering the logistical constraints and resources available for the study.
Furthermore, the strategic inclusion of multiple sites from different regions in Nigeria enhanced the generalizability and external validity of the findings despite the relatively small sample size.By capturing the diversity of experiences and nutritional challenges faced by HIV-infected children across various geographical locations, the study aimed to provide a comprehensive understanding of pediatric nutrition in the context of HIV/AIDS in Nigeria.

Quantitative variables handling and statistical methods
Advanced statistical methods were employed to analyze the quantitative variables and investigate the relationships between various factors influencing the nutritional status of HIV-infected children.These methods were selected to provide deeper insights into the complex dynamics of pediatric nutrition in the context of HIV/AIDS, thus enriching the interpretation of the study findings.

Multivariate regression analysis
To explore the independent associations between nutritional status indicators (e.g., body mass index [BMI] and heightfor-age) and potential predictors (e.g., age, gender, and highly active antiretroviral therapy [HAART] utilization), multivariate regression analysis was conducted.This approach allowed for the simultaneous examination of multiple variables while controlling for confounding factors, thereby elucidating the unique contributions of each predictor to the nutritional outcomes of HIV-infected children.

Logistic regression modeling
Logistic regression modeling was employed to assess the likelihood of malnutrition (e.g., underweight and stunting) among HIV-infected children based on various covariates, such as place of residence (rural vs urban), HAART utilization, and sociodemographic characteristics.By estimating odds ratios and their corresponding confidence intervals, this method facilitated a nuanced understanding of the factors influencing the prevalence of malnutrition in the study population.

Cluster analysis
Cluster analysis techniques, such as hierarchical clustering or k-means clustering, were utilized to identify distinct subgroups of HIV-infected children based on their nutritional profiles.This exploratory approach allowed for identifying homogeneous clusters of individuals with similar nutritional characteristics, thereby enabling targeted interventions tailored to each subgroup's specific needs.

Survival analysis
Given the longitudinal nature of the study and the importance of understanding the trajectory of nutritional status over time, survival analysis techniques, such as Kaplan-Meier survival curves and Cox proportional hazards models, were employed.These methods enabled the examination of time-to-event outcomes, such as the onset of severe malnutrition or recovery from undernutrition, while accounting for censoring and other sources of bias.

Structural equation modeling (SEM)
SEM was employed to elucidate the complex interrelationships between various determinants of pediatric nutrition.This comprehensive statistical approach allowed for constructing a theoretical model encompassing multiple pathways through which HIV/AIDS, socioeconomic factors, and other variables influence nutritional outcomes.By assessing the direct and indirect effects of these factors on pediatric nutrition, SEM facilitated a holistic understanding of the underlying mechanisms driving malnutrition among HIV-infected children.
Adopting these advanced statistical methods, the study aimed to enrich quantitative data analysis and provide robust evidence to support the conclusions drawn.By incorporating sophisticated analytical techniques, the study sought to enhance the credibility and scientific rigor of the findings, thus contributing to advancing knowledge in pediatric nutrition and HIV/AIDS.

Participants
From October 2018 to January 2019, 99 patients were recruited.Of these, 51 were females, and 48 were males.The majority (64) resided in rural areas.Among the participants, 92 were on HAART.

Descriptive data
There were no missing data for any of the variables of interest.The mean age of the participants was 9.72 years, with a standard deviation of 3.11 years.The MUAC was 13.16 cm, with a standard deviation of 0.51 cm.

Main results
To determine the nutritional status of HIV-infected children at the Federal University Teaching Hospital Owerri using BMI, 20 of 99 (20.2%)children were found to be underweight.In addition, 69.7% were classified as normal weight, 4% as overweight, and 6.1% as obese.

General characteristics of subjects
The participant characteristics in my study shed light on the diverse composition of HIV-infected children presenting at the Federal University Teaching Hospital Owerri (formerly Federal Medical Center Owerri), Nigeria.Through a detailed analysis of age, gender, place of residence, and antiretroviral therapy (ART) utilization, I gain valuable insights into the unique profiles of these vulnerable individuals.

ART utilization.
ART is a cornerstone of HIV management, particularly in pediatric populations.In my study, a significant proportion of HIV-infected children (92.9%) were receiving ART, underscoring the widespread adoption and accessibility of HIV treatment services.However, it is essential to address barriers to ART adherence and retention in care to ensure optimal health outcomes for HIV-infected children.By exploring the utilization of ART among study participants, I gain valuable insights into the impact of treatment adherence on nutritional status and overall well-being.

Nutritional status of children living with HIV
The nutritional status of HIV-infected children is a multifaceted issue influenced by a myriad of factors, including socioeconomic status, access to healthcare, dietary intake, and the impact of HIV/AIDS on metabolic processes.In my study conducted at the Federal University Teaching Hospital Owerri (formerly Federal Medical Center Owerri), Nigeria, I aimed to elucidate the nutritional status of HIV-infected children and its implications for their health and well-being.Table 3

Challenges of overweight and obesity.
Although less prevalent compared to underweight status, my study identified a notable proportion of HIV-infected children classified as overweight (4.0%) or obese (6.1%).This finding is particularly concerning as overweight and obesity are associated with an increased risk of metabolic complications, cardiovascular disease, and insulin resistance, further complicating the management of HIV/AIDS in affected children.3.5.7.Rural-urban disparities.Analysis of nutritional status by place of residence revealed interesting trends.All forms of malnutrition were more common among children residing in rural areas than among urban dwellers.However, these differences did not reach statistical significance (P = .41),highlighting the complex interplay of socioeconomic and environmental factors influencing nutritional outcomes in HIV-infected children.Table 4 compares study participants' nutritional status in rural and urban areas.

Other analyses
No other analyses, such as subgroup or sensitivity analyses, were conducted in this study.By presenting comprehensive results, including participant characteristics, nutritional status, and comparisons between urban and rural dwellers, this study provides valuable insights into the nutritional status of HIV-infected children in the specified setting.

Key results
This study aimed to assess the nutritional status of HIV-infected children aged 2 to 16 years attending the Federal University Teaching Hospital Owerri, Imo State, South East Nigeria, and compare the anthropometry of urban and rural dwelling children living with HIV. [11]y findings revealed that 20.2% of the study population were underweight, while 29.3% were stunted.These results are consistent with previous studies conducted by Fagbamigbe et al [12] and Hien and Kam, [13] suggesting a concerning prevalence of malnutrition among HIV-infected children in Nigeria.
However, it is noteworthy that the prevalence of underweight and stunting observed in my study was lower than that reported in studies conducted by Hunter et al. [14] In Central and West Africa, as well as in the study by Weigel et al in Malawi, this disparity may be attributed to the fact that most of my study participants were on HAART and were not immunosuppressed, unlike the participants in the Malawi study who were initiating HAART at the time of the study. [15]n addition, my findings indicated that underweight and stunting were more prevalent among rural dwellers compared to urban counterparts.9][20][21][22]

Interpretation of findings
My study revealed several key findings regarding the nutritional status of HIV-infected children, with notable proportions classified as underweight, normal weight, overweight, and obese based on BMI criteria.The prevalence of underweight among HIV-infected children underscores the persistent challenges of malnutrition in this population, highlighting the urgent need for targeted nutritional interventions to improve health outcomes.In addition, the presence of overweight and obesity raises concerns regarding metabolic complications and long-term health implications, necessitating comprehensive strategies to address both undernutrition and overnutrition in HIV-infected children. [6]

Understanding socioeconomic disparities
The disparities in nutritional status observed between rural and urban-dwelling children in my study underscore the influence of socioeconomic factors on health outcomes.While all forms of malnutrition were more common among rural children, the lack of statistical significance highlights the complexity of this issue and the need for further exploration.Socioeconomic disparities, limited access to healthcare services, and food insecurity likely contribute to the higher prevalence of malnutrition among rural populations, emphasizing the importance of holistic approaches to address these underlying determinants of health. [10]

Implications for clinical practice
My study's findings have important implications for clinical practice and public health policy.Healthcare providers working with HIV-infected children must prioritize comprehensive nutritional assessments and interventions as part of routine care.This includes regular monitoring of anthropometric measurements, dietary counseling, and supplementation as needed to address nutrient deficiencies.In addition, healthcare systems and policymakers must prioritize investments in nutrition-sensitive interventions and social safety nets to alleviate food insecurity and address underlying socioeconomic disparities contributing to malnutrition. [11]

Limitations and future directions
While my study provides valuable insights into the nutritional status of HIV-infected children, it is not without limitations.The table compares the nutritional status of participants by their place of residence.Stunting was observed in 29.3% of the participants, with no statistically significant difference between rural and urban dwellers.
cross-sectional design limits my ability to establish causality or assess long-term trends in nutritional status. [23]In addition, the study was conducted at a single center, which may limit the generalizability of findings to other settings within Nigeria or beyond.Future research should adopt longitudinal study designs and incorporate multicenter collaborations to enhance the representativeness and generalizability of findings. [15]

Methodological considerations
The methodological approach employed in my study, including the use of BMI as a proxy for nutritional status and the assessment of rural-urban disparities, offers valuable insights into the nutritional landscape of HIV-infected children.However, future studies should consider additional measures of nutritional status, such as dietary intake assessments, biochemical markers, and clinical outcomes, to provide a more comprehensive understanding of nutritional health in this population. [16]

Generalizability
The generalizability of my findings may be limited by the study's single-center design, which restricts the diversity of the participant population and the variability in healthcare practices that may exist across different institutions.However, the consistent patterns observed in previous studies conducted in similar contexts provide some support for the broader applicability of my results to other settings within Nigeria and potentially across sub-Saharan Africa.

Conclusion
This study provides valuable insights into the nutritional status of HIV-infected children attending the Federal University Teaching Hospital Owerri, Nigeria.Our findings underscore the significant burden of malnutrition, with a notable proportion of children being underweight and stunted.
Despite the advances in HIV treatment, disparities in nutritional outcomes persist, particularly among rural dwellers.Addressing these disparities requires a multifaceted approach, including targeted interventions to improve access to healthcare services, nutritional support, and socioeconomic assistance for vulnerable populations.
Furthermore, our study highlights the importance of ongoing monitoring and evaluation of nutritional status among HIVinfected children to inform evidence-based interventions and improve long-term health outcomes.
Moving forward, concerted efforts from healthcare providers, policymakers, and community stakeholders are needed to address the complex interplay between HIV infection and malnutrition and ensure equitable access to care for all affected children.
By addressing the underlying determinants of malnutrition and strengthening healthcare systems, we can strive towards achieving optimal health and well-being for HIV-infected children in Nigeria and beyond.
Table 1 presents the general characteristics of participants, and Table 2 displays the demographic characteristics of the study participants, including age, gender distribution, place of residence, age band, and HAART utilization.3.4.1.Age distribution.The age distribution of HIV-infected children included in my study ranged from 2 to 16 years, with a mean age of 9.72 years (standard deviation = 3.11).This diversity Elendu • Medicine (2024) 103:34 Medicine in age reflects the continuum of pediatric patients affected by HIV/AIDS, spanning from early childhood to adolescence.By encompassing a wide age range, my study captures the varying developmental stages and healthcare needs of HIV-infected children, providing a comprehensive understanding of their demographic profile.
3.4.4.Age band distribution.The distribution of HIV-infected children across different age bands provides valuable insights into the age-specific vulnerabilities and healthcare needs within this population.Most participants fell within the age bands of 5 to 9 years (43.4%) and 10 to 14 years (39.4%),reflecting the transitional phases of childhood and adolescence.In addition, a smaller proportion of children were observed in the age bands of 0 to 4 years (5.1%) and 15 to 19 years (12.1%),highlighting the continuum of care required from early childhood through adolescence into young adulthood.
provides an overview of the nutritional status of HIV-infected children based on their BMI classification.It highlights the distribution of underweight, normal-weight, overweight, and obese children within the study population.
3.5.4.Normal nutritional status.The majority of HIV-infected children in my study (69.7%) were classified as having a normal nutritional status based on BMI criteria.While this may seem reassuring, it is essential to recognize that normal BMI does not necessarily equate to optimal nutritional status.Many HIV-infected children may experience nutrient deficiencies and micronutrient imbalances despite falling within the normal BMI range, highlighting the importance of comprehensive nutritional assessments beyond BMI alone.

Table 1
General characteristics of participants.
The table presents the general characteristics of the study participants, including age and MUAC.MUAC = mid-upper arm circumference, SD = standard deviation.

Table 2
Demographic characteristics of participants.Addressing malnutrition in HIV-infected children.The high prevalence of malnutrition among HIV-infected children underscores the urgent need for comprehensive nutritional interventions tailored to their unique needs.Such interventions should encompass a multidisciplinary approach, including nutritional counseling, supplementation, and access to nutrientdense foods.Addressing underlying socioeconomic disparities, food insecurity, and access to healthcare services is essential for improving dietary outcomes in this vulnerable population.

Table 3
Nutritional status of children living with HIV.
The table displays the distribution of BMI classifications among HIV-infected children.All forms of malnutrition, including underweight and overweight, were more common among children living in rural areas than urban dwellers although this difference was not statistically significant (P = 0.41).BMI = body mass index, HIV = human immunodeficiency virus.

Table 4
Nutritional status of participants by place of residence.